Provider Escalation and Education Senior Manager

Devoted; United States; Remote; USD 111,000 - 150,000; Full time

Benefits offered by this job

Health, dental, and vision plan

Monthly stipend for mobile/internet

Stock options

Bonus eligibility for most roles

Parental leave

401K program

And more

Job summary

Devoted Health seeks a seasoned professional to own complex claims disputes and pricing appeals, driving end-to-end resolution with a focus on payment integrity and regulatory compliance. You will research CMS policies, lead RCCA initiatives, and partner with tech teams to streamline workflows.

You will guide training for distributed teams and ensure accurate, timely determinations, contributing to a culture of excellence across claims operations.

Qualifications

• 6–8+ years of experience in healthcare claims processing, payment integrity, coding appeals, or revenue cycle operations.
• Deep operational mastery of CMS guidelines, MAC coverage policies, NCCI edits, MUEs, and fee schedule logic.
• Proven track record researching, interpreting, and applying Medicare/CMS statutes and billing policies to resolve high-stakes disputes.
• Structured RCCA initiatives delivering measurable results.
• Exceptional attention to detail in complex claims determinations.
• Excellent written and verbal communication to distill regulatory information for executives.
• Advanced analytics using Excel/Sheets, SQL, or BI tools to track CTM and appeals metrics.
• Experience training or guiding distributed teams and external vendors.

Responsibilities

• Serve as escalation authority for complex claims disputes, OON pricing appeals, coding and billing challenges.
• Own end-to-end resolution of high-priority CTM cases, appeals, and provider disputes.
• Lead research into CMS guidelines, LCDs/NCDs, and federal regulations to support pricing and appeals.
• Partner with technical teams to build automation and AI-enabled workflows for intake, routing, and drafting.
• Ensure CTM investigations and provider disputes meet regulatory compliance and SLAs.
• Design RCCA programs to identify systemic vulnerabilities and bottlenecks.
• Collaborate with Claims Engineering, Configuration, and Payment Integrity to apply system fixes.
• Establish reporting rhythms and escalation protocols for leadership visibility.
• Educate vendor and offshore teams on regulatory changes via training and SOPs.

Skills

Healthcare claims processing

Payment integrity

Coding appeals

Revenue cycle operations

CMS guidelines mastery

NCCI edits/MUEs

Regulatory compliance

Data analysis

Communication skills

Training distributed teams

Tools

SQL

Tableau

Looker

Excel/Google Sheets

Job description

Your Responsibilities and Impact will include:

• Serving as the ultimate escalation authority for highly complex claims disputes, Out-of-Network (OON) pricing appeals, and intricate coding and billing challenges, including MUEs, NCCI edits, unbundling, and multiple procedure reductions
• Owning end-to-end resolution of high-priority Complaints Tracking Module (CTM) cases, appeals, and complex provider disputes, with clear accountability for accuracy, timeliness, and payment integrity
• Leading rigorous research into evolving CMS guidelines, MAC coverage policies, LCDs/NCDs, and federal regulations to support and defend pricing and appeal determinations
• Partnering with technical teams to build automation, custom logic rules, and AI-enabled workflows that streamline intake, routing, and preliminary drafting for appeals and escalations
• Ensuring every CTM investigation and provider dispute resolution meets regulatory compliance standards and SLA benchmarks
• Designing and running a Root Cause and Corrective Action (RCCA) program that identifies systemic vulnerabilities, configuration errors, and claims processing bottlenecks
• Partnering with Claims Engineering, Configuration, and Payment Integrity teams to implement system-level fixes that eliminate recurring provider friction before it reaches regulatory visibility
• Establishing reporting rhythms and escalation protocols that give executive and cross-functional leadership clear visibility into trends, emerging risks, and regulatory friction points
• Serving as the primary educational authority for vendor and offshore teams, converting complex regulatory changes into scalable training, SOPs, and job aids

Required skills and experience:

• 6–8+ years of hands‑on experience in healthcare claims processing, payment integrity, coding appeals, or revenue cycle operations
• Deep operational mastery of CMS guidelines, MAC coverage policies, NCCI edits, MUEs, multiple procedure reduction rules, and fee schedule logic
• Proven track record of independently researching, interpreting, and applying complex Medicare/CMS statutes and billing policies to resolve high‑stakes disputes
• Demonstrated experience designing and executing structured Root Cause and Corrective Action (RCCA) initiatives that deliver measurable results
• Exceptional attention to detail, with a reputation for getting complex claims determinations exactly right
• Excellent written and verbal communication skills, with the ability to distill technical regulatory and claims information into clear narratives for executive decision‑making
• Advanced analytical skills using Excel/Google Sheets, SQL, or BI tools (e.g., Tableau, Looker) to track CTM and appeals metrics and identify operational trends
• Experience training or guiding distributed teams and external vendors

Desired skills and experience:

• Certified Professional Coder (CPC) credential
• Experience deploying automation or AI‑enabled workflows in a claims or appeals environment

Salary range: $110,500 - $150,000 /year

Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well‑being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world‑class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer.

We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives.

This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business. As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.